Reducing suicides in mental healthcare: results from a 4-year follow-up implementation study in the Netherlands (SUPRANET).

Objective: In 2016, the SUicide PRevention Action NETwork (SUPRANET) was launched. The SUPRANET intervention aims at better implementing the suicide prevention guideline. An implementation study was developed to evaluate the impact of SUPRANET over time on three outcomes: 1) suicides, 2) registration of suicide attempts, and 3) professionals' knowledge and adherence to the guideline. Methods: This study included 13 institutions, and used an uncontrolled longitudinal prospective design, collecting biannual data on a 2-level structure (institutional and team level). Suicides and suicide attempts were extracted from data systems. Professionals' knowledge and adherence were measured using a self-report questionnaire. A three-step interrupted time series analysis (ITSA) was performed for the first two outcomes. Step 1 assessed whether institutions executed the SUPRANET intervention as intended. Step 2 examined if institutions complied with the four guideline recommendations. Based on steps 1 and 2, institutions were classified as below or above average and after that, included as moderators in step 3 to examine the effect of SUPRANET over time compared to the baseline. The third outcome was analyzed with a longitudinal multilevel regression analysis, and tested for moderation. Results: After institutions were labeled based on their efforts and investments made (below average vs above average), we found no statistically significant difference in suicides (standardized mortality ratio) between the two groups relative to the baseline. Institutions labeled as above average did register significantly more suicide attempts directly after the start of the intervention (78.8 per 100,000 patients, p<0.001, 95%CI=(51.3 per 100,000, 106.4 per 100,000)), and as the study progressed, they continued to report a significantly greater improvement in the number of registered attempts compared with institutions assigned as below average (8.7 per 100,000 patients per half year, p=0.004, 95%CI=(3.3 per 100,000, 14.1 per 100,000)). Professionals working at institutions that invested more in the SUPRANET activities adhered significantly better to the guideline over time (b=1.39, 95%CI=(0.12,2.65), p=0.032). Conclusion: Institutions labeled as above average registered significantly more suicide attempts and also better adhered to the guideline compared with institutions that had performed less well. Although no convincing intervention effect on suicides was found within the study period, we do think that this network is potentially able to reduce suicides. Continuous investments and fully implementing as many guideline recommendations as possible are essential to achieve the biggest drop in suicides.

Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta-analysis.

Psychotherapies are first-line treatments for most mental disorders, but their absolute outcomes (i.e., response and remission rates) are not well studied, despite the relevance of such information for health care users, providers and policy makers. We aimed to examine absolute and relative outcomes of psychotherapies across eight mental disorders: major depressive disorder (MDD), social anxiety disorder, panic disorder, generalized anxiety disorder (GAD), specific phobia, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and borderline personality disorder (BPD). We used a series of living systematic reviews included in the Metapsy initiative (www.metapsy.org), with a common strategy for literature search, inclusion of studies and extraction of data, and a common format for the analyses. Literature search was conducted in major bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane Register of Controlled Trials) up to January 1, 2023. We included randomized controlled trials comparing psychotherapies for any of the eight mental disorders, established by a diagnostic interview, with a control group (waitlist, care-as-usual, or pill placebo). We conducted random-effects model pairwise meta-analyses. The main outcome was the absolute rate of response (at least 50% symptom reduction between baseline and post-test) in the treatment and control conditions. Secondary outcomes included the relative risk (RR) of response, and the number needed to treat (NNT). Random-effects meta-analyses of the included 441 trials (33,881 patients) indicated modest response rates for psychotherapies: 0.42 (95% CI: 0.39-0.45) for MDD; 0.38 (95% CI: 0.33-0.43) for PTSD; 0.38 (95% CI: 0.30-0.47) for OCD; 0.38 (95% CI: 0.33-0.43) for panic disorder; 0.36 (95% CI: 0.30-0.42) for GAD; 0.32 (95% CI: 0.29-0.37) for social anxiety disorder; 0.32 (95% CI: 0.23-0.42) for specific phobia; and 0.24 (95% CI: 0.15-0.36) for BPD. Most sensitivity analyses broadly supported these findings. The RRs were significant for all disorders, except BPD. Our conclusion is that most psychotherapies for the eight mental disorders are effective compared with control conditions, but absolute response rates are modest. More effective treatments and interventions for those not responding to a first-line treatment are needed.

Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis.

A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.

Guidelines improve patient outcomes in specialised mental health care: A systematic review and meta-analysis.

OBJECTIVE: The uptake of evidence-based guideline recommendations appears to be challenging. In the midst of the discussion on how to overcome these barriers, the question of whether the use of guidelines leads to improved patient outcomes threatens to be overlooked. This study examined the effectiveness of evidence-based guidelines for all psychiatric disorders on patient health outcomes in specialist mental health care. All types of evidence-based guidelines, such as psychological and medication-focused guidelines, were eligible for inclusion. Provider performance was measured as a secondary outcome. Time to remission when treated with the guidelines was also examined. METHOD: Six databases were searched until 10 August 2020. Studies were selected, and data were extracted independently according to the PRISMA guidelines. Random effects meta-analyses were used to pool estimates across studies. Risk of bias was assessed according to the Cochrane Effective Practice and Organization of Care Review Group criteria. PROSPERO: CRD42020171311. RESULTS: The meta-analysis included 18 studies (N = 5380). Guidelines showed a positive significant effect size on the severity of psychopathological symptoms at the patient level when compared to treatment-as-usual (TAU) (d = 0.29, 95%-CI = (0.19, 0.40), p < 0.001). Removal of a potential outlier gave globally the same results with Cohen's d = 0.26. Time to remission was shorter in the guideline treatment compared with TAU (HR = 1.54, 95%-CI = (1.29, 1.84), p = 0.001, n = 3). CONCLUSIONS: Patients cared for with guideline-adherent treatments improve to a greater degree and more quickly than patients treated with TAU. Knowledge on the mechanisms of change during guideline-adherent treatment needs to be developed further such that we can provide the best possible treatment to patients in routine care.

Comprehensive database and individual patient data meta-analysis of randomised controlled trials on psychotherapies reducing suicidal thoughts and behaviour: study protocol.

INTRODUCTION: Psychotherapy may reduce suicidal thoughts and behaviour, but its effectiveness is not well examined. Furthermore, conventional meta-analyses are unable to test possible effects of moderators affecting this relationship. This protocol outlines the building of a comprehensive database of the literature in this research field. In addition, we will conduct an individual patient data meta-analysis (IPD-MA) to establish the effectiveness of psychotherapy in reducing suicidality, and to examine which factors moderate the efficacy of these interventions. METHODS AND ANALYSIS: To build a comprehensive database, randomised controlled trials examining the effect of any psychotherapy targeting any psychiatric disorder on suicidal thoughts or behaviour will be identified by running a systematic search in PubMed, Embase, PsycINFO, Web of Science, Scopus and The Cochrane Central Register of Controlled Trials from data inception to 12 August 2019. For the IPD-MA, we will focus on adult outpatients with suicidal ideation or behaviour. In addition, as a comparison group we will focus on a control group (waiting-list, care as usual or placebo). A 1-stage IPD-MA will be used to determine the effectiveness of psychotherapy on suicidal ideation, suicide attempts and/or suicide deaths, and to investigate potential patient-related and intervention-related moderators. Subgroup and sensitivity analyses will be conducted to test the robustness of the findings. Additionally, a conventional MA will be conducted to determine the differences between studies that provided IPD and those that did not. IPD-MA may determine the effectiveness of psychotherapy in reducing suicidality and provide insights into the moderating factors influencing the efficacy of psychotherapy. Answering these questions will inform mental healthcare practitioners about optimal treatments for different groups of individuals with suicidal ideation and/or behaviour and consequently help to reduce suicide risk. ETHICS AND DISSEMINATION: An ethical approval is not required for this study. The results will be published in a peer-review journal. PROSPERO REGISTRATION NUMBER: CRD42020140573.

Prioritizing suicide prevention guideline recommendations in specialist mental healthcare: a Delphi study.

BACKGROUND: The Delphi technique is a proven and reliable method to create common definitions and to achieve convergence of opinion. This study aimed to prioritize suicide prevention guideline recommendations and to develop a set of quality indicators (QIs) for suicide prevention in specialist mental healthcare. METHODS: This study selected 12 key recommendations from the guideline to modify them into QIs. After feedback from two face-to-face workgroup sessions, 11 recommendations were rephrased and selected to serve as QIs. Next, a Delphi study with the 11 QIs was performed to achieve convergence of opinion among a panel of 90 participants (23 suicide experts, 23 members of patients' advisory boards or experts with experiences in suicidal behavior and 44 mental healthcare professionals). The participants scored the 11 QIs on two selection criteria: relevance (it affects the number of suicides in the institution) and action orientation (institutions or professionals themselves can influence it) using a 5-point Likert scale. Also, data analysts working in mental healthcare institutions (MHIs) rated each QI on feasibility (is it feasible to monitor and extract from existing systems). Consensus was defined as 70% agreement with priority scores of four or five. RESULTS: Out of the 11 recommendations, participants prioritized five recommendations as relevant and action-oriented in optimizing the quality of care for suicide prevention: 1) screening for suicidal thoughts and behavior, 2) safety plan, 3) early follow-up on discharge, 4) continuity of care and 5) involving family or significant others. Only one of the 11 recommendations early follow-up on discharge reached consensus on all three selection criteria (relevance, action orientation, and feasibility). CONCLUSIONS: The prioritization of relevant and action-oriented suicide prevention guideline recommendations is an important step towards the improvement of quality of care in specialist mental healthcare.

Feasibility and impact of data-driven learning within the suicide prevention action network of thirteen specialist mental healthcare institutions (SUPRANET Care) in the Netherlands: a study protocol.

INTRODUCTION: Improvement of the quality and safety of care is associated with lower suicide rates among mental healthcare patients. In The Netherlands, about 40% of all people that die by suicide is in specialist mental healthcare. Unfortunately, the degree of implementation of suicide prevention policies and best practices within Dutch mental healthcare services is variable. Sharing and comparing outcome and performance data in confidential networks of professionals working in different organisations can be effective in reducing practice variability within and across organisations and improving quality of care. METHODS AND ANALYSIS: Using formats of professional networks to improve surgical care (Dutch Initiative for Clinical Auditing) and somatic intensive care (National Intensive Care Evaluation), 113 Suicide Prevention has taken the lead in the formation of a Suicide Prevention Action Network (SUPRANET Care), with at present 13 large Dutch specialist mental health institutions. Data on suicide, suicide attempts and their determinants as well as consumer care policies and practices are collected biannually, after consensus rounds in which key professionals define what data are relevant to collect, how it is operationalised, retrieved and will be analysed. To evaluate the impact of SUPRANET Care, standardised suicide rates will be calculated adjusted for confounding factors. Second, the extent to which suicide attempts are being registered will be analysed with the suicide attempt data. Finally, professionals' knowledge, attitude and adherence to suicide prevention guidelines will be measured with an extended version of the Professionals In Training to STOP suicide survey. ETHICS AND DISSEMINATION: This study has been approved by the Central Committee on Research Involving Human Subjects, The Netherlands. This study does not fall under the scope of the Medical Research Involving Human Subjects Act (WMO) or the General Data Protection Regulation as stated by the Dutch Data Protection Authority because data are collected on an aggregated level.

Changing patient perspectives after compulsory admission and the risk of re-admission during 5 years of follow-up: The Amsterdam Study of Acute Psychiatry IX.

OBJECTIVE: Given increasing numbers of compulsory admissions, it is important to assess patient risk profiles and identify factors that are appropriate for intervention. METHODS: A sample of 116 patients who were compulsorily admitted was studied. Socio-demographic and clinical characteristics were recorded. Patients were interviewed twice using the Verona Service Satisfaction Scale and the Birchwood Insight Scale. Changes in insight and satisfaction during 2 years were linked to the incidence of involuntary re-admissions in the next three follow-up years. RESULTS: A higher mean score for patient satisfaction was found (mean=3.77, standard deviation (SD)=0.56; p⩽.001) in the second interview than in the baseline interview (mean=3.26, SD=0.65). There was also an improvement in insight (in the second interview: mean=7.22, SD=2.86 and in the baseline interview: mean=6.34, SD=3.18; p=.027). There was an inverse correlation between increasing satisfaction (in years 1-2) and the incidence of involuntary admission in years 3-5 (odds ratio (OR)=0.445, 95% confidence interval (CI)=0.252-0.793; p=.006). This association proved to be dependent on a history of involuntary admission. CONCLUSION: Increasing patient satisfaction in the first 2 years was associated with a lower risk of compulsory re-admission in the subsequent follow-up period, but this association proved to be dependent on a history of involuntary admissions in these first two follow-up years. Increase in insight during the same period did not show any effect whatsoever.